I was looking up something in the Medicare coding & reimbursment stuff and came across an early ruling on autoCPAPs. It seems the manufactures originally wanted to have them coded as BiPAPs, but Medicare said no- they do not meet the difinition of BiPAP and are not significantly different then regular CPAP so they couldn't get their own code either. I can imagine that the manufactures weren't too happy about that since that meant they couldn't charge the $2500-3000 (retail) they do for regular BiPAPs...and it looked like the decision wasn't made until after the first autoCPAPs were approved so you know that had to hurt their projected profits.
I did find a statement from Aetna regarding autoCPAP & BiPAP for OSA: "BiPAP, DPAP, VPAP, and AutoPAP are considered medically necessary DME for members who are intolerant to CPAP. These alternatives to CPAP may also be considered medically necessary for OSA members with concomitant breathing disorders, which include restrictive thoracic disorders, COPD, and nocturnal hypoventilation." http://www.aetna.com/cpb/data/CPBA0004.html Most insurances probably have something similar in their policies. I don't think autoCPAPs are even mentioned in the Meidcare regulations since they are considered the same as regular CPAP to them.
What do I say to get an Auto???
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WillSucceed
- Posts: 1031
- Joined: Sun Nov 07, 2004 7:52 am
- Location: Toronto, Ontario
Biggziff wrote:
The problem was that I could not get him to even give me the time of day. He had his billing in place as I had already had the sleep studies and was, in my opinion, much more interested in going on to the next patient's sleep study (read: billing) than he was in helping me get good treatment.
He solved my chest pain problems that I was having by giving me a script for an autoPAP. This simple response effectively solved my chest pain problem AND his I-have-a-patient-who-is-not-prepared-to-be-ignored-or-treated-like-crap-now-that-I-have-received-my-billing-from-OHIP problem.
If he honestly believed that the autoPAP was inappropriate treatment (like your example of giving an antibiotic when not needed) he would have been practicing bad medicine to give it to me. I'm very disinclined to believe that an autoPAP is likely to harm a patient whereas inappropriate use of an antibiotic certainly could.
The College of Physcians and Surgeons would likely be alot more concerned about him practicing bad medicine than they would about me feeling ignored by him.
Not-withstanding, there are different types of treatment (CPAP, AutoPAP, Bi-level, surgery, dental devices...) and the patient is, in my opinion, well within his/her rights to be fully informed about treatment options and, fully involved in decision-making regarding these options. I believe that patients should demand that their Dr. spend time with them relative to both assessment AND treatment. Further, patient should be able to say ( and be heard) his/her wishes regarding treatment. Any Dr. that slinks away after the sleep study (read: I've got my billing, job finished) should be held accountable -that is what their medical board and/or College is for.
Comparing this issue to inappropriate use of antibiotics is, I think, a poor comparison and might give readers of this thread the notion that they are not to challenge their Dr. regarding assessment/treatment of their OSA. I've read many threads on this forum from folk who have felt that their Dr. was not nearly as involved in their treatment as they would have liked, or benefited from and they have been held powerless by the Dr.-is-god crap. We should always advocate for ourselves, even if this means hauling a Dr. up in front of their governing body.
Read the post thoroughly, would you, before you get judgemental. I was clear that I had made multiple calls/faxes to his office and to the supplier. My comment was that I was considering a complaint regarding the Dr.'s lack of interest/response regarding my concerns/contacts, not that he was not giving me what I wanted. Sure, I wanted an autoPAP, but would have backed off if he had given me ANY rational for me not having one.This is on par to me demanding an antibiotic for my kids when they complain that their ear hurts
The problem was that I could not get him to even give me the time of day. He had his billing in place as I had already had the sleep studies and was, in my opinion, much more interested in going on to the next patient's sleep study (read: billing) than he was in helping me get good treatment.
He solved my chest pain problems that I was having by giving me a script for an autoPAP. This simple response effectively solved my chest pain problem AND his I-have-a-patient-who-is-not-prepared-to-be-ignored-or-treated-like-crap-now-that-I-have-received-my-billing-from-OHIP problem.
If he honestly believed that the autoPAP was inappropriate treatment (like your example of giving an antibiotic when not needed) he would have been practicing bad medicine to give it to me. I'm very disinclined to believe that an autoPAP is likely to harm a patient whereas inappropriate use of an antibiotic certainly could.
The College of Physcians and Surgeons would likely be alot more concerned about him practicing bad medicine than they would about me feeling ignored by him.
Not-withstanding, there are different types of treatment (CPAP, AutoPAP, Bi-level, surgery, dental devices...) and the patient is, in my opinion, well within his/her rights to be fully informed about treatment options and, fully involved in decision-making regarding these options. I believe that patients should demand that their Dr. spend time with them relative to both assessment AND treatment. Further, patient should be able to say ( and be heard) his/her wishes regarding treatment. Any Dr. that slinks away after the sleep study (read: I've got my billing, job finished) should be held accountable -that is what their medical board and/or College is for.
Comparing this issue to inappropriate use of antibiotics is, I think, a poor comparison and might give readers of this thread the notion that they are not to challenge their Dr. regarding assessment/treatment of their OSA. I've read many threads on this forum from folk who have felt that their Dr. was not nearly as involved in their treatment as they would have liked, or benefited from and they have been held powerless by the Dr.-is-god crap. We should always advocate for ourselves, even if this means hauling a Dr. up in front of their governing body.
Buy a new hat, drink a good wine, treat yourself, and someone you love, to a new bauble, live while you are alive... you never know when the mid-town bus is going to have your name written across its front bumper!
Bigziff,
Seems to me that another tact might be to go back to your GP or primary care Doc and convince him/her to give you the Rx for an APAP, to take the Sleep specialist out of the loop so to speak.
I'm just speculating here... has that worked for anyone else?
I also like Wader's point about just buying the auto machine outright, since you've already got compatible hardware and software. Sounds like the CPAP Rx gives you that flexibility.
Seems to me that another tact might be to go back to your GP or primary care Doc and convince him/her to give you the Rx for an APAP, to take the Sleep specialist out of the loop so to speak.
I'm just speculating here... has that worked for anyone else?
I also like Wader's point about just buying the auto machine outright, since you've already got compatible hardware and software. Sounds like the CPAP Rx gives you that flexibility.
Understood...I was playing Devil's Advocate. My question still stands though...did the insurance co actually PAY for this unit or is it rented until they verify compliance?
My rationale is simple. I did well on 7-9...my pressure needs change depending on how I sleep (back/side etc) I required much less pressure on my side than on my back. I generally sleep changing from back to side during the night. If I need 11 on my back, but 7-9 on my side, it would seem to my feeble brain that an auto is the perfect solution.
[quote="wading thru the muck!"]Biggziff,
Not to suggest you were trying to commit fraud. I would be interested in your rationale suggesting an auto. You have a similar range to what I have, in fact I was titrated at 7cm and with my auto 90% of my events are prevented at a pressure of 9cm or below. I am fully in favor of everyone getting an auto, but the way the insurance reimbursement system is currently set up, there is no reason for a DME to provide apaps when a cpap will work. Interestingly Respironics (the makers of the REMstar machines) would recomend switching to a Bi-pap if cpap is not tolerated. Their position regarding autopaps is that they are to be used for a limited term to verify and/or adjust lab titrated pressure settings. I suspect this position is politically motivated to please the DMEs.
My rationale is simple. I did well on 7-9...my pressure needs change depending on how I sleep (back/side etc) I required much less pressure on my side than on my back. I generally sleep changing from back to side during the night. If I need 11 on my back, but 7-9 on my side, it would seem to my feeble brain that an auto is the perfect solution.
[quote="wading thru the muck!"]Biggziff,
Not to suggest you were trying to commit fraud. I would be interested in your rationale suggesting an auto. You have a similar range to what I have, in fact I was titrated at 7cm and with my auto 90% of my events are prevented at a pressure of 9cm or below. I am fully in favor of everyone getting an auto, but the way the insurance reimbursement system is currently set up, there is no reason for a DME to provide apaps when a cpap will work. Interestingly Respironics (the makers of the REMstar machines) would recomend switching to a Bi-pap if cpap is not tolerated. Their position regarding autopaps is that they are to be used for a limited term to verify and/or adjust lab titrated pressure settings. I suspect this position is politically motivated to please the DMEs.
WHOA there cowboy!!WillSucceed wrote:Biggziff wrote:Read the post thoroughly, would you, before you get judgemental.This is on par to me demanding an antibiotic for my kids when they complain that their ear hurts
I was referring to my situation...no one else's. Sorry you took it that way.
I fully agree that knowledge is power. In my line of work, knowing more than the other guy makes me successful. Same hold true for life. This is why I'm gathering as much data as possible so when I present to the doc again, he'll either have to agree or give me something I hadn't thought about as a reason why. He is suspect already in that I'm at a higher pressure than I deem to be necessary. I may not be a doctor, but I can read and learn *very* quickly. This stuff isn't rocket science.
Again...don't take it so seriously...not aimed at you personally and I did read your entire post.
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wading thru the muck!
- Posts: 2799
- Joined: Tue Oct 19, 2004 11:42 am
It all makes sense to me and that is why I bought an auto machine... but in the world of the medical provider/insurance industry they would be just as satisfied putting you on a fixed pressure cpap at 11cm. Some argue that you should not be on anything but this. To those of us who use the machine each day, every cm we can whittle off our therapy is of great benefit.biggziff wrote:My rationale is simple. I did well on 7-9...my pressure needs change depending on how I sleep (back/side etc) I required much less pressure on my side than on my back. I generally sleep changing from back to side during the night. If I need 11 on my back, but 7-9 on my side, it would seem to my feeble brain that an auto is the perfect solution.
Sincerely,
wading thru the muck of the sleep study/DME/Insurance money pit!
wading thru the muck of the sleep study/DME/Insurance money pit!
I really didn't have to do much to convince my doc to prescribe the AutoPAP for me. Once he could tell that I had done my research and knew what I was talking about (more than him even), he had no problem with it, though he was initially very hesitant. Another thing that helped me, I had talked to my DME about some of the issues that I was having, mainly still snoring, and he agreed with me that auto was probably what I needed. So, I was able to use that when talking to the doc to help convince him.
Now that I have my APAP machine, I don't think I could go back to straight CPAP.
Now that I have my APAP machine, I don't think I could go back to straight CPAP.
how to get auto.....
Well, i suggest the compliance tactic. Tell your doc that the in hospital sleep study did not accurately reflect your "normal" sleep patterns and cycles. You proceed to explain that with the autopap you will have "real numbers" from "real sleep". This will make you as the patient apt to be more informed and more inclined to be compliant. An educated consumer is the best customer, right? Tell him about the great sleep logs you will present at your next visit.
Me, well I got mine the fat route. I refused the presented CPAP with the rationale that I was going to lose weight and I would need a lower titrated pressure very soon. It worked too.
Me, well I got mine the fat route. I refused the presented CPAP with the rationale that I was going to lose weight and I would need a lower titrated pressure very soon. It worked too.
FANTASTIC information in this thread!
I just got my CPAP machine (rented by my insurance company via a DME) a little over a week ago. Oddly, I'm having good days where I feel just spectacular, and bad days where I feel like I didn't use CPAP at all (but did the whole night). I'm thinking my prescribed pressure isn't right, or is right sometimes but not others.
I just yesterday managed to get a hold of my official CPAP titration study results. They are disappointing - basically the end result was (paraphrased), "patient seemed to respond best at 7cm but not enough time was spent at that pressure to confirm. Recommend another CPAP titration if 7cm doesn't resolve symptoms." Bah!
So now I want an Auto machine, because I don't have a ton of faith in CPAP titration studies and don't want to go through another.
I've just sent information off to billmyinsurance.com to see what they can find out for me if I want to return the rented REMStar Pro2 and buy a REMStar Auto. Insurance bought the heated humidifier and mask, but rented the REMStar Pro2... If I can swing it that I return the REMStar Pro2 and pay only the deductible I'll just buy the darned Auto and be done with it... I pushed (lightly) for an auto from the DME but they of course said no, that it has to be "prescribed" specifically from my doctor or insurance won't pay.
I just got my CPAP machine (rented by my insurance company via a DME) a little over a week ago. Oddly, I'm having good days where I feel just spectacular, and bad days where I feel like I didn't use CPAP at all (but did the whole night). I'm thinking my prescribed pressure isn't right, or is right sometimes but not others.
I just yesterday managed to get a hold of my official CPAP titration study results. They are disappointing - basically the end result was (paraphrased), "patient seemed to respond best at 7cm but not enough time was spent at that pressure to confirm. Recommend another CPAP titration if 7cm doesn't resolve symptoms." Bah!
So now I want an Auto machine, because I don't have a ton of faith in CPAP titration studies and don't want to go through another.
I've just sent information off to billmyinsurance.com to see what they can find out for me if I want to return the rented REMStar Pro2 and buy a REMStar Auto. Insurance bought the heated humidifier and mask, but rented the REMStar Pro2... If I can swing it that I return the REMStar Pro2 and pay only the deductible I'll just buy the darned Auto and be done with it... I pushed (lightly) for an auto from the DME but they of course said no, that it has to be "prescribed" specifically from my doctor or insurance won't pay.
--FJC (Frank)
Having a positive attitude makes a huge difference in CPAP therapy - and vice versa!
Ride that loop!
Having a positive attitude makes a huge difference in CPAP therapy - and vice versa!
Ride that loop!